Book Summary: Dreamland

Book: Dreamland—The True Tale of America’s Opiate Epidemic

Author: Sam Quinones

 

A Short History of the Heroine molecule:

  • Opium has been used for millennia from Egyptians to Greeks, and then the expanding Arab Empire and Venetians.
  • In the early 1800s. Friedrich Sertuner isolate the sleep-inducing element in opium and called it Morphine, after Morpheus, the Greek god of sleep.
  • Wars helped spread morphine across continents, and of course, caused wars (e.g. Opium wars in China)
  • In 1874, Dr. Alder Wright in London first created diacetylmorphine, a molecule that was thought to be a non-addictive version of morphine. In 1898, a German chemist working at Bayer reproduced this molecule and called it heroine, named after heroisch (German for the word “heroic”, because that is how the test subject felt upon using it). Again, at this point heroin was considered non-addictive.

 

Arthur Sackler: Pfizer was built on success of a drug called Terramycin, which was one of the first marketed drugs, and the the consultant on this project was Arthur Sackler. Upon seeing the success of targeted pharmaceutical advertising, Sackler bought the firm he worked for, William Douglas McAdams. In ’63, he bought the licensing rights to Valium from Hoffman La-Roche and emphasized direct doctor contact to promote the drug, after which Valium became the first $100 mm drug and then the first $1 bn drug (Hoffman La-Roche was accused of not warning people of the drug’s addictive potential). Arthur Sackler died in ’87 and was one of the first five inductees in the Medical Advertising Hall of Fame.

 

Changing Attitude Toward Pain: As anesthesiologists gained a new role in medicine, more and more of these guys became pain specialists. In ’96, the president of American Pain Society stated that pain needs to be treated as a vital sign, after which they trademarked the slogan “Pain: The Fifth Vital Sign”. This was taken up in ’98 by the Veterans Health Administration, and then by the JCAHO (Joint Commission for Accreditation of Healthcare Organizations)–which accredits 16,000 healthcare orgs in the U.S. Hospitals were now judged how they assessed and treated a patient’s pain; CA legislature required hospitals and nursing homes to screen for pain.

Despite all this, docs were worried about the potential of addiction, and demanded legal clarity. In response to this, beginning with CA, states passed laws exempting doctors from prosecution if they prescribed opiates for pain within the practice of responsible healthcare. Many other states (OH, OR, WA, and others) approved these so-called intractable pain regulations.

Press Ganey surveys in the ’90s unwittingly helped spread use of pain medication, as the surveys gauged patient satisfaction (who were always happier with the pills taking away the pain).

 

The Landmark Study:  A purported study of low-dosage of opiates for inpatient admissions, in presence of medical professionals was done by Drs. Porter and Jick, and it concluded that “less than 1 percent” of patients got addicted. This study was cited as a footnote in a ’86 paper by Foley and Portenoy in Pain. From then on, the citations of the study took a life of its own, and somehow this statistic was being used to assume addiction rates for chronic pain patients going home with bottles of pills. Furthermore, the Porter & Jick “study” was not a study, but a one-paragraph letter to the NEJM editor.

With time and associated distortions, this one-paragraph letter was cited in some books as a “landmark study” and more and more pills were prescribed, which also spelled bad times for the more complicated multi-disciplinary approach to pain (from 1,000 such clinics in ’98, only 85 survived by ’05).

 

Oxycontin Arrives on the Scene:  In 1995, the FDA approved Oxycontin for 10, 20, and 40 mg pills (80 and 160 mg pills were added later). FDA approved a unique warning label that stated that Oxycontin is less susceptible to abuse vs. other oxycodone products because of timed-release formula (Oxycodone was developed in 1917 in Germany as one of several semi-synthetic opioids). This claim was the cornerstone of Oxycontin’s marketing and no other Schedule II narcotic ever got to make such a claim. With this claim in bag, Purdue started marketing Oxycontin in the same fashion as it had marketed Valium in the ’60s: as virtually non-addictive.

Partners Against Pain was founded in ’97 to offer consumers information about pain treatment options including Oxy. Purdue also had funded websites such as FamilyPractice.com, offering docs free CME programs on pain management; and American Pain Foundation (which disbanded in 2012 after a Senate investigation followed a ProPublica investigation). Purdue created organizations that were meant to look grassroots, funded them generously, and then had these organization approach state medical boards about liberalizing regulations for prescribing.

By 2003, more than half the prescribers of Oxy were primary care docs, who had little pain-management training, and were under pressure to get patients in and out of their offices. Over time, as is the wont of capitalism, the extreme forms of profiteers arrived in form of pill mills, once people such as David Procter, the Godfather of the Pill Mill showed the way.

A decade after Oxycontin’s release, 6.1 mm people had abused it, which is staggering when you think that at its height, the crack epidemic involved fewer than 0.5 mm users per year.

 

Tenderized by Opiates, Addicts Turned to Heroin:  The Xalisco boys from Nayarit used Methadone clinics in the western U.S. cities to expand beyond the San Fernando Valley in the early ’90s. Every cell learned to find a methadone clinic and gave away free samples of heroin to the addicts. They learned to sell only to the whites, which was in part due to negative perception of the black people in Mexico (because of returning immigrants who had lived in Compton, Watts and South Central LA), which is how the use of black tar expanded across the U.S., but mostly in white communities.

 

Recovery Is Hard:  After kicking opiates, it takes roughly two years for dopamine receptors to start working naturally, which is why it is extremely hard to successfully complete rehab. People cite success rates of 1/10. One addiction specialist suggested that had these opiates not appeared, he’d have seen the same number of people later in their lives (say, 20 years or so), addicted with alcoholism because that’s how long it took people to get addicted enough to seek treatment.

 


 

Random Tidbits:

  • The state of Washington worker’s compensation systems is one of the only 5 in country that hold monopolies on insuring workers. The state insures 2/3rd of all Washington’s workers, and oversees the rest, who are insured by companies large enough to self-insure.
  • In Floyd country, Kentucky, coal-miners worked in the mines until 45, when they’d be pushed out because of black lung but with a monthly check from a federal disability program called SSDI (Social Security Disability Insurance), which would be large enough to somehow support a family. This was a life strategy in eastern KY (which I personally find incredibly sad).
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